Food for thought. Department of Health Services Research 1

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1 Food for thought Suppose you have been asked to undertake an economic evaluation of the costs and effects on the Fall prevention program Identify the range of different costs that you might wish to include in your analysis bearing in mind the impact on the society Department of Health Services Research 1

2 Economic evaluation of falls: accept the challenge Silvia Evers Professor of Public Health Technology Assessment Maastricht University Dept. HSR Maastricht University Department of Health Services Research Department of Health Services Research 2

3 Content: Why economic evaluation What is economic evaluation Economic evaluation of falls Could we make a promiss? Department of Health Services Research 3

4 Why economic evaluation Department of Health Services Research 4

5 E.g. interventions for any disorders Interventions Psychologist GP Physical activity Dietician Home care Medications Other therapies Department of Health Services Research 5

6 lead to improved outcomes Interventions Psychologist GP Physical activity Dietician Home care Medications Other therapies Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life Department of Health Services Research 6

7 and lower long-term costs Interventions Psychologist GP Physical activity Dietician Home care Medications Other therapies Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life Cost savings Lower use of health and social care services Fewer out-ofpocket expenses Greater economic productivity Higher income Department of Health Services Research 7

8 Pertinent economic questions Interventions Psychologist GP Physical activity Dietician Home care Medications Other therapies Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life Cost savings Lower use of health and social care services Fewer out-ofpocket expenses Greater economic productivity Higher income Department of Health Services Research 8

9 Pertinent economic questions Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life Cost savings Lower use of health and social care services Fewer out-ofpocket expenses Greater economic productivity Higher income Department of Health Services Research 9

10 Pertinent economic questions Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life Cost savings Lower use of health and social care services Fewer out-ofpocket expenses Greater economic productivity Higher income Department of Health Services Research 10

11 But why? Scarcity Not enough resources to meet all of society s needs or wants Department of Health Services Research 11

12 Why economics (1) Increased spending in (Western) on health care Budget cuts in several countries, so important question is sustainability of financing Importance of cost-effectiveness research, next to effectiveness research Department of Health Services Research 12

13 Why economics (2) More intervention are developed and there is an increasing need for healthcare interventions Financial barriers are increasing, for instance for reimbursement, basis package Rising demand for evidence based (economic) evaluation information Funding agencies Health care insurance Ministry of Health, EU In other words, if you are really an advocate of your intervention and want to improve the sustainability (reimbursement) include an economic evaluation in your effectiveness study Department of Health Services Research 13

14 What is economic evaluation Department of Health Services Research 14

15 Economic Evaluation costs A Intervention A outcome A costs B Intervention B outcome B difference in costs? difference in outcome? relationship? Department of Health Services Research 15

16 Two things different from outcome/ effectiveness/intervention research Measuring and valuing societal costs of both the new intervention and care as usual Measuring and valuing QALY of both the new intervention and care as usual Department of Health Services Research 16

17 Societal costs Informal care Social care Sector Truancy Sector Health Care Sector Sector What else? Sector Sector Sector Household activities Out of pocket expenses Department of Health Services Research 17

18 Quality Adjusted Life Years (QALYs) Combination of survival * utilities Utility is how good you feel in a number 0 is death an 1 full health Derived by using the questionnaire for instance the EuroQoL Department of Health Services Research 18

19 EuroQol questions ( Health Status Mobility 1. No problems walking 2. Some problem walking about 3. Confined to bed Self-care 1. No problems with self-care 2. Some problems washing or dressing self 3. Unable to wash or dress self Usual activities 1. No problems with performing usual activities (e.g. work, study, housework, family or leisure activities) 2. Some problems with performing usual activities 3. Unable to perform usual activities Pain/discomfort 1. No pain or discomfort 2. Moderate pain or discomfort 3. Extreme pain or discomfort Anxiety/depression 1. Not anxious or depressed 2. Moderately anxious or depressed 3. Extremely anxious or depressed

20 Visual analogue scale (rating scale)

21 Combining duration of life with HRQL 1.0 Health profile without intervention Area under the curve: 0 QUALITY ADJUSTED LIFE YEARS Time in years t

22 An individual QALY gain 1.0 Health profile with intervention Health profile without intervention Time in years t

23 Calculation of a ratio New interventions Alternative costs effects costs effects Cost-effectiveness ratio: C n - C a E n - E a Department of Health Services Research 23

24 Incremental Cost-Effectiveness Ratio (ICER) C e = costs of experimental program C e - C c E e - E c < λ C c = costs of conventional program E e = effectiveness of experimental program E c = effectiveness of conventional program λ = Willingness to pay for a certain ICER Department of Health Services Research 24

25 When is an intervention cost-effective? More costs New intervention = More expensive & Less effective New intervention = More expensive & More effective Less effects More effects New intervention = Less expensive & Less effective New intervention = Less expensive & More effective Less costs Department of Health Services Research 25

26 Economic evaluation of falls Department of Health Services Research 26

27 Cost of falls in NL The mean costs per fall were 9,370 Higher for women ( 9,990) than men ( 7,510) Increased with age ( 3,900 at ages years to 14,600 at ages 85 year) Conclusions: fall-related injuries are leading to a high healthcare consumption (costs), which increases with age Hartholt et al Injury 2012 Jul;43(7): Department of Health Services Research 27

28 Department of Health Services Research 28

29 Fall Prevention Gillespie Cochrane review (2001- ) Multifactorial & multidisciplinary intervention programmes Close et al. (Lancet, 1999): medical occupational therapy assessment vs. usual healthcare promising results in British setting replication in Dutch healthcare Department of Health Services Research 29

30 Design Randomized Controlled Trial (n = 333) 1 year follow up Effect evaluation Economic evaluation Process evaluation Is the multidisciplinary intervention programme preferable to usual care in the Netherlands when assessed from a societal perspective? Hendriks et al. (BMC Public Health, 2005) Department of Health Services Research 30

31 Participants Community dwelling 65+ Visited A&E department because of a fall High risk group! Department of Health Services Research 31

32 Intervention To identify and address risk factors for falling Medical Assessment Geriatrician, Physiatrist, Geriatric nurse Hospital Occupational-Therapy Assessment Occupational therapist At home Recommendations and/or referral if indicated Department of Health Services Research 32

33 Medical assessment general examination blood pressure vision & sense of hearing peripheral nervous system loco motor apparatus feet & footwear balance & mobility length & weight cognition & affect medication heart & blood tests Results GP Occupational-therapy assessment Results Participant Department of Health Services Research 33

34 Intervention Medical assessment Results GP Occupational-therapy assessment functioning environmental risk factors psychological consequences Recommendations Home adaptations Assistive devices Homecare Behavioral change Participant Department of Health Services Research 34

35 Flow chart Control group N = 167 FU 1 86% FU 2 80% Baseline N = 333 Randomization Intervention group N = 166 Received intervention 83% FU 1 79% FU 2 75% 0 months 4 months 12 months Department of Health Services Research 35

36 Costs identification Healthcare costs Program costs GP Hospital Paramedics and alternative medicine Medical aids and assistive devices Formal care Medication Other Patient & family costs Informal care Paid domestic help Home modifications Department of Health Services Research 36

37 Measurements Cost diary & Fall calendar Continuous; 12 months Monthly interview by telephone Cost diary volumes Programme costs average time spent on assessments Self-administered questionnaire Quality of life Clinical outcomes Baseline, after 4 and after 12 months Department of Health Services Research 37

38 Costs Valuation Volume x Cost price Dutch manual for costing-research methods and guideline-prices Shadow prices for informal care No discounting Department of Health Services Research 38

39 Health Outcomes CEA Specific: Falls (% persons at least 1 fall) Generic: Functioning (Frenchai Activity Index) CUA Generic: QALY (EQ-5D) Specific: Falls Handicap Inventory (FHI) Department of Health Services Research 39

40 Results: Healthcare Costs Programme 385 Intervention Control P-value Mean (sd) Mean (sd) GP 161 (171) 190 (210).22 Hospital 1,232 (1,633) 1,763 (2,960).08 Paramedics 376 (628) 364 (512).87 Aids & devices 355 (787) 205 (421).07 Formal Care 1,119 (2188) 1,400 (4,538).54 Medication 149 (127) 150 (122).95 Other 63 (647) 58 (624).96 TOTAL 3,839 (3,707) 4,313 (6,035).65 Department of Health Services Research 40

41 Results: Patient & Family Costs Intervention Control P-value Mean (sd) Mean (sd) Informal Care 446 (1,308) 327 (1,238).46 Paid domestic help 274 (710) 291 (598).83 Home modification 298 (834) 242 (916).62 TOTAL 1,018 (1624) 860 (1,952).49 Department of Health Services Research 41

42 intervention control % Falls p = Functioning p =.32 QALY p = Falls 0,9 60 0,8 0,7 50 0,6 40 0,5 0,4 30 0,3 20 0,2 10 0,1 0 0 Handicap Inventory p =.19 Department of Health Services Research 42

43 Bootstrap and sensitivity Additional costs -0,20-0,15-0,10-0,05-0,05 0, Additional effects Department of Health Services Research 43

44 Recommendations Not (cost-)effective However.only short term costs and outcome Not implementing in current form in the Netherlands Process evaluation aspects to optimize: More acute screening Avoid delay in referral (through GP) Department of Health Services Research 44

45 Upcoming study Evaluating an in-home multicomponent cognitive behavioural programme to manage concerns about falls and associated activity avoidance in frail community-dwelling older people: Design of a randomised control trial [NCT ] Promising results in the economic evaluation Department of Health Services Research 45

46 Suppose you are Going to do a trial, RCT, case-control, etc. Include cost questionnaire Include quality of life questionnaire (EQ-5D) Are doing a trial, without economics That s a stupid! pity!.any other economic question Have a lot of evidence without any trial Consider model-based study Choice experiments SR including economics Always consult HE and HTA experts from scratch Department of Health Services Research 46

47 In conclusion: core statements Economic studies are another way of highlighting the importance of falls next to epidemiological measures Economic evaluation studies highlight the impact of intervention on the society, in terms of costs and effects Always execute an economic evaluation study when evaluating the effectiveness of a fall intervention Department of Health Services Research 47

48 Thanks!, and could we make a promise? For more information; s.evers@maastrichtuniverisity.nl Accept the challenge Oath of economic evaluation I,, do solemnly and sincerely promise and swear (or declare) that I will truly and faithfully, and to the best of my skill and knowledge, always execute an economic evaluation study and consult an health economics expert when evaluating an intervention, so help me God You can do it Department of Health Services Research 48

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